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Fundamentals Test 2 > Chapter 27 > Flashcards

Chapter 27 Flashcards

1
Q

The nurse’s first action after discovering an electrical fire in a patient’s room is to:

1 Activate the fire alarm.

2 Confine the fire by closing all doors and windows.

3 Remove all patients in immediate danger.

4 Extinguish the fire by using the nearest fire extinguisher.

A

Remove all patients in immediate danger. RACE –remove, activate,contain, extinguish

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2
Q

A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

1 Give the child milk.

2 Give the child syrup of ipecac.

3 Call the poison control center.

4 Take the child to the emergency department

A

Call the poison control center.

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3
Q

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

1 Activity intolerance

2 Impaired bed mobility

3 Acute pain

4 Risk for falls

A

Risk of falls

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4
Q

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

1 Home accidents

2 Physiological changes of aging

3 Poisoning and child abduction

4 Automobile accidents, suicide, and substance abuse

A

Automobile accidents, suicide, and substance abuse

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5
Q

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

1 Insert a urinary catheter.

2 Leave a night light on in the bathroom.

3 Ask the physician to order a restraint.

4 Keep the bed in low position with upper and lower side rails up.

5 Assign a staff member to stay with the patient.

6 Provide scheduled toileting during the night shift.
7 Keep the pathway from the bed to the bathroom clear.

A
  1. Leave a night light on in the bathroom,
  2. provide scheduled toileting during the night shift,
  3. keep the pathway from the bed to the bathroom clear.
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6
Q

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

1 Contact the nursing supervisor.

2 Restrict the family’s visiting privileges.

3 Ask the family to stay with the patient if possible.

4 Inform the family of the risks associated with side-rail use.

5 Thank the family for being conscientious and put the four rails up.

6 Discuss alternatives with the family that are appropriate for this patient.

A
  1. Ask the family to stay with the patient if possible
  2. Inform the family of the risks associated with side-rail use.
  3. Discuss alternatives with the family that are appropriate for this patient.
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7
Q

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order.

___ 1 Explain what you plan to do.

___ 2 Wrap a limb restraint around wrist or ankle with soft part toward skin and secure.

___ 3 Determine that restraint alternatives fail to ensure patient’s safety.

___ 4 Identify the patient using proper identifier.

___ 5 Pad the patient’s wrist.

A
  1. Determine the restraint alternatives fail to ensure patients safety.
  2. Identify the patient using proper identifier
  3. Explain what you plan to do.
  4. Pad the patient’s wrist.
  5. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure
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8
Q

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?

1 Begin cardiopulmonary respiration.

2 Restrain the child to prevent injury.

3 Place a tongue blade over the tongue to prevent aspiration.

4 Clear the area around the child to protect the child from injury.

A

Clear the area around the child to protect the child from injury.

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9
Q

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

1 A safe environment promotes patient activity.

2 Assessment focuses on environmental factors only.

3 Teaching home safety is difficult to do in the hospital setting.

4 Most accidents in the older adult are caused by lifestyle factors.

A

a safe environment promotes patient activity

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10
Q

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

1 Place a bed alarm device on the bed.

2 Place the patient in a belt restraint.

3 Provide one-on-one observation of the patient.

4 Apply wrist restraints.

A

Place a bed alarm device on the bed.

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11
Q

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.)

1 Smoking is prohibited around oxygen.

2 Demonstrate how to adjust the oxygen flow rate based on patient symptoms.

3 Do not use electrical equipment around oxygen.

4 Special precautions may be required when traveling with oxygen

A
  1. Smoking is prohibited around oxygen
  2. Do not use electrical equipment around oxygen
  3. Special precautions may be required when traveling with oxygen.
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12
Q

How does the nurse support a culture of safety? (Select all that apply.)

1 Completing incident reports when appropriate

2 Completing incident reports for a near miss

3 Communicating product concerns to an immediate supervisor

4 Identifying the person responsible for an incident

A
  1. Completing incident reports when appropriate
  2. Completing incident reports for a near miss
  3. Communicating product concerns to an immediate supervisor
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13
Q

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

1 Smokes a pack a day

2 Used a cane to walk at home

3 Takes antihypertensive and diuretics

4 History of recent fall

5 Neglect, spatial and perceptual abilities, impulsive

6 Requires assistance with activity, unsteady gait

7 IV line, urinary catheter

A
  1. Takes antihypertensive and diuretics
  2. History of recent fall
  3. Neglect, spatial and perceptual abilities, impulsive
  4. Requires assistance with activity, unsteady gait
  5. IV line, urinary catheter
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14
Q

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?

1 Prepare for an influx of patients

2 Contract the American Red Cross

3 Determine how to restore essential services

4 Evacuate patients per the disaster plan

A

Prepare for an influx of patientsUse

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15
Q

Identify the 6 Joint Commission 2011 National Patient Safety Goals for Hospitals

A
  1. Identify patients correctly (using two identifiers.)
  2. Improve staff communication (timely reporting of test results.)
  3. Use medicines safely (labeling)
  4. Reduce the risk of HAI (hand washing and safe practices)
  5. Check patient medicines
    6.Identify Patient safety
    7.
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16
Q

Besides being knowledgeable about the environment, nurses must be familiar with what 4 things?

A
  1. Patient’s developmental level
  2. Mobility, sensory, and cognitive status
  3. Lifestyle Choices
  4. Knowledge of common safety precautions
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17
Q

Identify the individual risk factors that can pose a threat to safety (4)

A
  1. lifestyle
    2 impaired mobility
  2. sensory or communication impairment
  3. Lack of sensory awareness
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18
Q

List the four major risks to patient safety in the health care environment.

A
  1. Falls
  2. Patient-inherent accidents (seizures, burns, inflicted cuts)
  3. Procedure-related accidents (med admin, improper procedures)
  4. Equipment-related accidents (rapid Iv infusions, Electrical hazards)
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19
Q

Identify the specific patient assessments to perform when considering possible threats to the patient’s safety (5)

A
  1. nursing history
  2. Patient’s home environment
  3. Health Care environment
  4. Risk for falls
  5. Risk for medial errors
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20
Q

Identify the features that should alert nurses to the possibility of a bioterrorism-related outbreak. (5)

A
  1. A disease (or strain) not endemic
  2. Unusual antibiotic resistance patterns
  3. atypical clinical presentation
  4. Clusters of patients arriving from a single locale
  5. Other inconsistent elements ( number of cases, mortality and morbidity rates)
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21
Q

Identify actual and potential nursing dx that apply to patients whose safety is threatened. (9)

A
  1. Risk for falls
  2. Impaired home maintenance
  3. Risk for injury
  4. Deficient knowledge
  5. Risk for poisoning
  6. Risk for contamination
  7. Risk for suffocation
  8. Risk for Thermal injury
  9. Risk for trauma
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22
Q

Identify the plan for a patient who has a “high risk for falls” (3)

A
  1. Select nursing interventions to promote safety according to patient’s developmental and health care needs
  2. Consult with OT and PT for assistive devices
  3. Select interventions that will improve the safety of the patient’s home environment
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23
Q

Identify the strategies needed to provide safe nursing care. (3)

A
  1. Demonstrate effective use of technology and standardized practices that support safety and quality
  2. Demonstrate effective use of strategies to reduce the risk of harm to self and others
  3. use appropriate strategies to reduce reliance on memory
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24
Q

A physical restraint is___

A

a human, mechanical, or physical device that is used with or without the patients permission to restrict his or her freedom of movement or normal access to a persons body and is not a usual part of the treatment

25
Q

Use of restraints must meet the following objectives (4)

A
  1. reduce the risk of patient injury from falls
  2. prevent interruption of therapy
  3. prevent a confused or combative patient from removing life support equipment
  4. Reduce the risk of injury to others by the patient
26
Q

Explain why an ambularm is used

A

to alert the staff when a patient is up and out of bed

27
Q

Explain the mnemonic RACE to set priorities in case of fire

A

R. Rescue- and remove all patients in immediate danger
A. Activate the alarm
C. Confine the fire by closing doors and windows and turning off oxygen and electrical equipment
E. Extinguish the fire using an extinguisher

28
Q

Explain seizure precautions

A

are nursing interventions to protect patients from traumatic injury, positioning for adequate ventilation and drainage or oral secretions, and providing privacy and support after the event.

29
Q

Identify the measures with which the nurse must be familiar to reduce exposure to radiation

A

Limits the time spent near the source, makes the distance from the source as great as possible, and uses shielding devices.

30
Q

The Joint Commission (2011) requires that hospitals have an emergency management plan that addresses: (3)

A
  1. The identification of possible emergency situations and their probable impact
  2. The maintenance of adequate an amount of supplies
  3. The formal response plan for staff and hospital operations
31
Q

Which of the following would most immediately threaten an individual’s safety?

  1. 70% humidity
  2. A sprained ankle
  3. Lack of water
  4. Unrefrigerated fresh vegetables

Give rationale

A

an individual’s safety is most threatened when physiological needs are not met, including the need for water, oxygen, basic nutrition, and optimum temperature

32
Q

The developmental stage that carries the highest risk of an injury from a fall is:

  1. Preschool
  2. Adulthood
  3. School Age
  4. Older Adulthood

Give Rationale

A

Older adulthood is the developmental stage that carries the highest risk of an injury from a fall because of the physiological changes that occur during the aging process, which increase the patient’s risk for falls

33
Q

Mrs. Field falls asleep while smoking in bed and drops the burning cigarette on her blanket. When she awakens, her bed is on fire, and she quickly calls the nurse. On observing the fire, the nurse should immediately:

  1. Report the fire
  2. Attempt to extinguish the fire
  3. Assist Mrs. Field to a safe place
  4. Close all windows and doors to contain the fire.

Give rationale

A

The nurse should use RACE to set priorities in case of fire. Rescue and remove all patients in immediate danger first

34
Q

Sixteen-year-old Jimmy is admitted to an adolescent unit with a diagnosis of substance abuse. The nurse examines Jimmy and fins that he has bloodshot eyes, slurred speech, and an unstable gait. He smells of alcohol and is unable to answer questions appropriately. The appropriate nursing diagnosis would be:

  1. Self-Care Deficit related to alcohol abuse
  2. Deficient Knowledge related to alcohol abuse
  3. Disturbed Thought Processes related to sensor overload.
  4. High Risk for Injury related to impaired sensory perception.

Give rationale

A

The related factors becomes the basis for the selection of nursing therapies

35
Q

The nurse’s first action after discovering an electrical fire in a patient’s room is to:

A. Activate the fire alarm.

B. Confine the fire by closing all doors and windows.

C. Remove all patients in immediate danger.

D. Extinguish the fire by using the nearest fire extinguisher.

A

Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.

36
Q

A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

A. Give the child milk.

B. Give the child syrup of ipecac.

C. Call the poison control center.

D. Take the child to the emergency department.

A

A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

37
Q

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

A. Activity intolerance

B. Impaired bed mobility

C. Acute pain

D. Risk for falls

A

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

38
Q

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

A. Home accidents

B. Physiological changes of aging

C. Poisoning and child abduction

D. Automobile accidents, suicide, and substance abuse

A

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

39
Q

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

A. Insert a urinary catheter.

B. Leave a night light on in the bathroom.

C. Ask the physician to order a restraint.

D. Keep the bed in low position with upper and lower side rails up.

E. Assign a staff member to stay with the patient.

F. Provide scheduled toileting during the night shift.

G. Keep the pathway from the bed to the bathroom clear.

A

B. Leave a night light on in the bathroom
F. Provide scheduled toileting during the night shift
G. Keep the pathway from the bed to the bathroom clear

Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

40
Q

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

A. Activity intolerance

B. Impaired bed mobility

C. Acute pain

D. Risk for falls

A

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

41
Q

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

A. Home accidents

B. Physiological changes of aging

C. Poisoning and child abduction

D. Automobile accidents, suicide, and substance abuse

A

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

42
Q

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

A. Insert a urinary catheter.

B. Leave a night light on in the bathroom.

C. Ask the physician to order a restraint.

D. Keep the bed in low position with upper and lower side rails up.

E. Assign a staff member to stay with the patient.

F. Provide scheduled toileting during the night shift.

G. Keep the pathway from the bed to the bathroom clear.

A

B. Leave a night light on in the bathroom
F. Provide scheduled toileting during the night shift
G. Keep the pathway from the bed to the bathroom clear

Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

43
Q

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

A. Activity intolerance

B. Impaired bed mobility

C. Acute pain

D. Risk for falls

A

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

44
Q

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

A. Home accidents

B. Physiological changes of aging

C. Poisoning and child abduction

D. Automobile accidents, suicide, and substance abuse

A

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

45
Q

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

A. Insert a urinary catheter.

B. Leave a night light on in the bathroom.

C. Ask the physician to order a restraint.

D. Keep the bed in low position with upper and lower side rails up.

E. Assign a staff member to stay with the patient.

F. Provide scheduled toileting during the night shift.

G. Keep the pathway from the bed to the bathroom clear.

A

B. Leave a night light on in the bathroom
F. Provide scheduled toileting during the night shift
G. Keep the pathway from the bed to the bathroom clear

Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

46
Q

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

A. Contact the nursing supervisor.

B. Restrict the family’s visiting privileges.
C. Ask the family to stay with the patient.
D. Inform the family of the risks associated with side-rail use.

E. Thank the family for being conscientious and put the four rails up.
F. Discuss alternatives with the family that are appropriate for this patient.

A

c. ask the family to stay with the patient
D. inform the family of the risks associated with side-rail use.
F. Discuss alternatives with the family that are appropriate for this patient.

The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

47
Q

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?
A. Begin cardiopulmonary respiration.

B. Restrain the child to prevent injury.

C. Place a tongue blade over the tongue to prevent aspiration.

D. Clear the area around the child to protect the child from injury.

A

D. Clear the area around the child to protect the child from injury.

Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

48
Q

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

A. A safe environment promotes patient activity.

B. Assessment focuses on environmental factors only.

C. Teaching home safety is difficult to do in the hospital setting.

D. Most accidents in the older adult are caused by lifestyle factors.

A

a. a safe environment promotes patient activity

Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

49
Q

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

A. Place a bed alarm device on the bed.

B. Place the patient in a belt restraint.

C. Provide one-on-one observation of the patient.

D. Apply wrist restraints.

A

a. place a bed alarm device on the bed

Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

50
Q

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.)

A. Smoking is prohibited around oxygen.

B. Demonstrate how to adjust the oxygen flow rate based on patient symptoms.

C. Do not use electrical equipment around oxygen.

D. Special precautions may be required when traveling with oxygen

A

a. Smoking is prohibited around O2
c. Do not use electrical equipment around oxygen
D. Special precautions may be required when traveling with oxygen.

When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting “Oxygen in Use” signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician’s order, and taking precautions when traveling with oxygen.

51
Q

How does the nurse support a culture of safety? (Select all that apply.)
A. Completing incident reports when appropriate

B. Completing incident reports for a near miss

C. Communicating product concerns to an immediate supervisor

D. Identifying the person responsible for an incident

A

a. Completing incident reports when appropriate
b. Completing incident reports for a near miss
c. Communicating product concerns to an immediate supervisor.

Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

52
Q

How does the nurse support a culture of safety? (Select all that apply.)
A. Completing incident reports when appropriate
B. Completing incident reports for a near miss
C. Communicating product concerns to an immediate supervisor

D. Identifying the person responsible for an incident

A

a. Completing incident reports when appropriate
b. completing incident reports fora near miss
c. Communicating product concerns to an immediate supervisor

Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

53
Q

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

A. Smokes a pack a day

B. Used a cane to walk at home

C. Takes antihypertensive and diuretics

D. History of recent fall

E. Neglect, spatial and perceptual abilities, impulsive

F. Requires assistance with activity, unsteady gait

G. IV line, urinary catheter

A

c. Takes antihypertensive and diuretics
D. Hx of recent fall
E. Neglect, spatial and perceptual abilities, impulsive
F. Requires assistance with activity, unsteady gait
g. IV line, urinary catheter

Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

54
Q

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?
A. Prepare for an influx of patients

B. Contact the American Red Cross

C. Determine how to restore essential services

D. Evacuate patients per the disaster plan

A

Prepare for an influx of patients

The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

55
Q

Home health nurse is in the home her chief concern for her patient is: (select all that apply)

A. basic needs are met
B. Reduces transmission of pathogens by hand washing
C. Reduces the likelihood of falls
D. Taking naps when the patient does

A

A. Basic needs are met
B. Reduces transmission of pathogens by hand washing
C. Reduces the likelihood of falls

The primary duty for nurses is to protect clients from harm and to keep clients safe.

56
Q 
As a nurse in the hospital setting, the nurse is made aware of a bomb on the floor.  Hospital policy aside, the nurse should use which mnemonic: ( select all that apply)
A.  SBAR
B.  APIE
C.  OLDCART
D.  RACE
A

SBAR and RACE

Situation, background, assessment, and recommendation
or
Rescue, Alarm, Contain, and Extinguish

SBAR in case you find the bomb or the policy and Race if there is a fire.

57
Q

Safety risk in the health care facility include but the following:

a. falls
b. medical errors
c. Chemical use
d. Client-inherent accidents
e. procedure related accidents
f. drowning

A

all but drowning are safety risks.

Drowning is not a concern

58
Q

A patient is confused and disorientated. She keeps getting out of bed and attempting to use the bathroom in the corner thinking it is the bathroom. What is the best course of action for a nurse:

a. Put a bedside toilet near the bedside and explain the use
b. restraints
c. Chemcial restraint
d. Light on for illumination, side rails up on one side of the bed, inform family members of the situation.

A

A. put a beside toilet near the bedside and explain the use
D. Light on for illumination, side rails up on one side of the bed and inform the family members of the situation.

Restraints are only used if absolutely necessary. They are physician ordered.

Fundamentals Test 2 (6 decks)

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